Total Questions
26
Category
Breast Surgery
Updated
May 2026
01
What is the difference between 19125 and 19301?
CPT 19125 is for excision of breast lesion where some radiological marker is placed preoperatively. CPT code 19301 is used, when complete breast tumor is resected along with margin.
02
What is Sentinel Lymph node?
Sentinel lymph node is the lymph node around the cancer site that is most likely to receive the spread from that cancer.
03
How will you identify the Lymph node biopsy is Superficial and deep ?
If the lymph nodes are biopsied or excised from the fascia or deeper layers, it is considered a deep biopsy.
However, if the lymph nodes are located in the outer region, such as the subcutaneous tissue, it is considered superficial biopsy.
For axillary lymph node biopsy or excision, documentation of the Clavipectoral fascia indicates a deep procedure
04
How do you code for excision of additional tissue for margins at the time of lumpectomy? Is there a code for the added work for the margins?
CPT codes 19120 and 19125 are used when a surgeon removes a breast lump without needing to check or remove extra tissue around it (no attention to margins). These are usually for non-cancerous lesions.
But when the surgery is for breast cancer, the surgeon must remove the tumor along with some surrounding tissue(margin) to make sure all cancer is gone. This is called a lumpectomy or partial mastectomy, and it is always reported with CPT code 19301.
05
How will you report if two different mass or tumor are resected with margin through two different incision of the same breast , can we report 19301 twice ?
No, report 19301 only once for same day of encounter. Also, it has only 1 MUE unit.
06
Can we code Adjacent tissue transfer, if performed for partial mastectomy closure ?
As per guideline, we cannot code Adjacent tissue transfer 14000,14001 for closure of partial mastectomy .
Also, Simple, intermediate and complex repair is included in partial mastectomy code (19301).
07
What is the meaning of Axillary Lymphadenectomy in CPT 19302, how many lymph node required to excised for this ?
For this CPT, there should be full dissection of lymph node , it should be only sampling of few lymph nodes.
For Axillary lymphadenectomy at least Level 1 and Level 2 lymph node should be resected. The physician can do seperate incision for this if required. A single incision is also sufficient for this code
08
Is excision of two lymph node are considered as axillary lymphadenoectomy ?
No, removal of all lymph nodes from at least Level I and Level II should be performed
09
Can you code for injection of radioactive tracer and blue dye for sentinel lymph node biopsy?
The correct answer is as If you inject a radioactive tracer preoperatively, report code 38792. Injection of blue dye, when performed, is included in the sentinel node code, 38900.
10
What is Skin sparing mastectomy and Nipple sparring mastectomy ?
Skin sparring mastectomy means removal of complete breast tissue but sparring the skin for immediate breast reconstruction.
Nipple sparring mastectomy means removal of complete breast tissue but sparring the nipple areolar complex.
But the CPT code for both is same as 19303.
11
How should I code for nipple-sparing mastectomy and skin-sparing mastectomy to distinguish them from total mastectomy?
Report all such procedure with code 19303.
12
What is removed during total mastectomy ?
In this, all breast tissue is removed excluding pectoralis muscle.
13
How will you report , if physician is doing Stereotactic guidance core biopsy but no localization device is placed ,?
You can still code 19081/19082 even if a localization device was not actually placed.
The CPT code description states ‘localization, if performed,’ so for coding purposes, the code remains the same whether or not the device was used.
14
What is prophylaxis mastectomy and how to report ?
Prophylaxis mastectomy is the removal of breast without having current cancer or tumor, it means surgeon is removing this as precaution ,because the patient already has cancer on other breast and also having genetic risk for cancer.
Report this procedure as mastectomy and also code Primary diagnosis as prophylaxis of mastectomy , Z40.01.
15
Medical necessity to code breast reduction ?
Hypertrophy of breast, Breast asymmetry
16
Why physician peforms capuslotomy at the time of removal of breast implan
The purpsose of capsulotomy is to remove the scar and to release capsular contracture 19370: Revision of peri-implant capsule, breast, including capsulotomy, capsulorrhaphy, and/or partial capsulectomy 19371: Peri-implant capsulectomy, breast, complete, including removal of all intracapsular contents
17
What is reconstruction of breast ?
Breast reconstruction is surgery to rebuild a breast after cancer or trauma. It restores the breast’s shape using implants or the patient’s own tissue and can be done immediately or later.
18
What is breast implant and why and when it is performed ?
A Breast implant is a medical device placed inside the breast to change its size, shape, or fullness. It is usually filled with: Silicone gel, or Saline (sterile salt water) Breast implants are used for: To enlarge the breasts (cosmetic augmentation)
19
How will you report , if both deep and superficial lymph nodes are sample through the same incision, can code code both 38500 and 38525 ?
No, you should code only 38525, as it more extensive procedure and the superficial biopsy or excision is included.
20
What are the difference between Radical Mastectomy and Modified radical masectomy
In Radical Mastectomy physician remove completed breast tissue with Pectoralis major and minor muscle along with Axillay Lymph node.
But in Modified Mastectomy, the physician spare the Pectroalis mejor muscle and rest they removed same as Radical.
21
What is Urban Type Procedure ?
Urban operation = Extended Radical Mastectomy
It involves:
Removal of the entire breast
Removal of axillary lymph nodes
Removal of internal mammary lymph nodes
CPT 19306 : Mastectomy, radical, including pectoral muscles, axillary and internal mammary lymph nodes (Urban type operation)
22
Can we code Mastopexy 19316 along with Nipple areolar reconstruction 19350 ? Newly added
No code only Mastopexy as Nipple/areolar reconstruction is included.
23
How will you report if liposuction of the breast is perform for reduction mammoplasty ? Newly added
Do not report liposuction 15777 separately. When liposuction is performed to assist or contour the breast during a reduction mammoplasty, it is considered integral to the primary procedure and is included in the reduction mammoplasty CPT code 19318.
24
What is the difference between a tissue expander and a breast implant? Newly added
A tissue expander is a temporary device placed after mastectomy to gradually stretch the skin and chest muscle using saline injections. Once adequate expansion is achieved, it is removed and replaced with a permanent breast implant, which restores the final breast shape.
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Tissue Expander = Temporary, first stage of breast reconstruction.
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Breast Implant = Permanent, final stage of reconstruction.
25
What is Autologous breast reconstruction? Newly added
Autologous breast reconstruction involves harvesting a flap of skin, subcutaenous fat and or muscle form one area of the body and relocating the tissue to the anterior chest to create a breast mound.
19361: Breast reconstruction; with latissimus dorsi flap
26
What is free flap in breast reconstruction and name some flap? Newly added
A free flap is a piece of tissue (skin, fat, muscle, or bone) that is completely removed from one part of the body and moved to another part, and its blood vessels are reconnected using microsurgery.
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fTRAM- Free Transverse Rectus abdominas Myocuataneous Flap
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DIEP - Deep Inferior Epigastric Perforator flap
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SIEA- Superficial Inferior Epigastric Artery flap
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GAP- Gluteal Artery Perforator flap.
27
Can we code ATT if the tissue is rotated/advanced/tranposed during breast reconstruction (19357- 19369)? Newly added
Dont Code ATT with breast reconstruction procedure.